Arthritis & Rheumatism (Arthritis Care & Research) Vol. 51, No. 6, December 15, 2004, pp 877– 880 DOI 10.1002/art.20835 © 2004, American College of Rheumatology
EDITORIAL
Fury Over Sound MARNIX
VAN
HOLSBEECK
An ultrasound examiner plays a transducer like an instrument. The art of handling ultrasound equipment derives from continual practice and from mental reflexes that instantly combine 3-dimensional knowledge of anatomy and pathology. Literally, skilled sonographers have knowledge at their fingertips. In scientific articles, ultrasound has been depicted more operator-dependent than any other imaging technique. The article by Brown et al (1), which derives information from questionnaires sent to both radiologists and rheumatologists, speculates that ultrasound transducers may play a role in the hands of rheumatologists. For almost 30 years, ultrasound has played a leading role in women’s imaging. Ultrasound is universally used in the diagnosis of pelvic pain, in the diagnosis of masses, and to follow pregnancies. Cardiac imaging too has benefited from ultrasound because of its capability of showing pericardium, myocardium, the function of valves, and the dynamics of blood flow within heart chambers. Both obstetric and cardiac ultrasound developed in an era when magnetic resonance imaging (MRI) and multidetector computerized tomography were not competitive modalities. Musculoskeletal ultrasound (MSUS), in contrast, has been a more recent trend in the use of ultrasound. The technique developed slowly and, from the beginning, competed with MRI. Early on, veterinary medicine was quick to embrace MSUS for the diagnosis of lameness in horses. This method applied to animals developed in the 1980s and continues to prove very successful (2). Recent technical developments have allowed the number of imaging tools available to musculoskeletal imagers to expand rapidly. It is hard to believe that physicians once ordered nothing but radiographs when a patient complained of shoulder pain. Back in those days, the shoulder was called the “forgotten joint” (3) because of the frequency of disease in the joint capsule that went unnoticed upon radiographic evaluation. With the shoulder as an example, the current assessment expands into both diagMarnix van Holsbeeck, MD: Wayne State Medical School, Detroit, Michigan. Address correspondence to Marnix van Holsbeeck, MD, Director Musculoskeletal Radiology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202. E-mail:
[email protected]. Submitted for publication August 18, 2004; accepted August 22, 2004.
nostic and therapeutic imaging. Shoulder ultrasound, computed tomography (CT), and MRI—with and without intraarticular contrast enhancement—all advance our knowledge of bone and joint diseases of the thoraco-scapulo-humeral region. In therapy, arthrography for brizement procedure, ultrasound-guided needling of calcium deposition, and arthroscopic repair of rotator cuff and labral tears minimize the incisions once used to treat shoulder disease (4). However, the improvement of diagnostic and therapeutic accuracy of imaging comes with a cost that society must be willing to pay. Ultrasound has the potential to reduce that cost; its overhead expenses represent only a fraction of MRI and CT. Not surprisingly, applications for musculoskeletal ultrasound keep growing and, as a result, interest in this dynamic imaging technique is increasing steadily. In planning future MSUS several questions need to be answered: What training should the musculoskeletal sonographer undergo? How should service be structured? What sort of reimbursement should one pursue? What research is needed?
Expertise Well then— has the time come for the portable ultrasound unit to replace the anatomy textbook in medical school? Should medical students place laptop ultrasound machines in their backpacks next to personal digital assistants and cellular phones? Indeed, the use of MSUS images may follow the path that the electrocardiogram (EKG) once trotted. At first, cardiologists had a monopoly on EKG, but then EKG spread to a great number of best practices. Now decades later, EKG equipment is present not only in most medical practices, but can also be found beyond medicine—fire trucks now have them as a requirement in the delivery of emergency services. If ultrasound blooms as the EKG once did, should ultrasound training start in residency or even before residency? If radiology, as Brown’s article (1) suggests, should not have a monopoly over MSUS, does this type of ultrasound belong in rheumatology, in orthopedics, or in physical medicine and rehabilitation? Or, as some believe, does ultrasound fit in the practice of podiatry, chiropractic, or in the athletic locker room? Indeed, some ultrasound equipment manufacturers directly market portable units to athletic trainers because they believe that ultrasound should have a wider reach and should extend its use beyond the medical field. In a first step toward a more general use of ultrasound in 877
878 musculoskeletal diseases, medical school may be the ideal place to introduce the comprehension of ultrasound images and of the technology that generates the pictures. However in all truth, we are still far from this utopia. Rheumatologists in Brown’s article (1) state in their questionnaires that they often learned ultrasound through contacts with radiologists. The majority of the clinicians had taken courses. In contrast, pioneering radiologists had started earlier with this new technique and they were more often self taught. The questionnaires did not probe the reasons for differences in the learning process between these groups of practitioners. Brown et al (1) sent their opinion polls to experts in MSUS. Many of these pioneers have a profile that does not represent the average profile of peers in their profession where ultrasound is concerned. It appears more befitting to check the current certification of radiologists and rheumatologists to distinguish who would be better users of this technique. In North America, 4 years of radiology residency training requires 4 months of ultrasound taught through hands-on practice, case solving, and lectures on ultrasound physics and technology. In most programs, that education will be spread evenly in 1-month blocks of time over the 4-year curriculum. The understanding of the imaging technique and its accompanying anatomy parallels education in cross-sectional anatomy and pathology as displayed by CT and MRI. In addition to these 4 months of training, radiology residents attend daily case presentations; in our program in the Henry Ford Health System for example, ultrasound will on average be presented a minimum of 2 hours per month for a total of ⬃100 hours of presentations over the course of residency. Fellowship training in musculoskeletal radiology adds an extra year to this curriculum. The bone and joint anatomy as visualized by ultrasound is taught along with the anatomy as seen through digital radiography, computerized tomography, and MRI. It is not surprising then that radiologists were able to pioneer ultrasound techniques that rheumatologists have now come to embrace. Far from being “self taught” in ultrasound as stated in Brown’s article, trainees enrolled in a radiology residency program follow rigorous instruction carefully monitored by the Accreditation Council on Graduate Medical Education (ACGME) and sanctioned by the American Board of Radiology (ABR) examination. The ABR has been administering written and oral examinations including sonography for ⬎25 years. The written boards test the residents’ knowledge of the physics of imaging techniques. The same examination assesses the residents’ aptitude in recognizing imaging signs of disease. The oral boards in radiology follow the next year; in that 5-hour examination, digital images of disease are shown to the board-eligible residents. A minimum of 10 unknown ultrasound cases is presented to the examinees; MSUS cases have been included in this examination for several years. The recognition and discussion of the pathologic images are part of the requirement for a passing grade leading to board certification in radiology. Rheumatology, in contrast, is a 2-year fellowship offered as subspecialization in internal medicine or in pediatrics. ACGME requirements for the fellowship focus on diagnosis and differential diagnosis of inflammatory musculo-
van Holsbeeck skeletal conditions, on injecting and aspirating joints, on microscopic synovial fluid analysis, and on integrating and applying imaging methods. With respect to imaging, the program requirements for residency education in rheumatology state that the facilities in which the rheumatologist should be trained must include CT and MRI. “There must be a meaningful working relationship, including teaching and consultation at the primary education site, with faculty in radiology and the program must provide sufficient experience for the resident to acquire skill in the performance or interpretation of bone and joint imaging techniques.” From these statements, one can conclude that the rheumatologist can learn the technique of ultrasound. Some clinicians even consider ultrasound an extension of the physical examination. However, in my personal opinion, I judge that radiology training prepares the trainee better for the 3-dimensional imaging challenges that the musculoskeletal sonographer faces in daily practice.
Service Although I believe that the radiologist has a better foundation on which to build a MSUS practice, issues other than training must be considered as well. It is not so much a question of who can and who cannot become capable of practicing ultrasound. The question appears more complex. What do patients gain from ultrasound in the hands of rheumatologists? Will it help rheumatologists to distinguish patients who need surgery from those who need medical treatment? Will it assist in choosing between different medical treatments? Or will it simply drive up the cost of practicing medicine? Let us first consider some factors with respect to organization of an ultrasound service. Studies in the past have shown that physicians who do not refer patients to radiologists but perform imaging in their own practice order 4 – 4.5 times more imaging. Socalled “self referring” imagers—a group of clinicians that could include the rheumatologists practicing ultrasound in the near future— drive the cost of imaging up 4.4 –7.5 times higher per episode of care (5). With the now strict anti– kick-back laws, referrals to radiologists contain cost on the presumption that a referral from a clinician to a radiologist is driven by pure necessity. The radiologist, as an impartial observer, has then been given authority to help determine by means of ultrasound who may need medical treatment and who may require surgery. Diametrically opposed to this, it is easy to portray the self referral as a vicious cycle. In our opinion, a self-referring imager might find it difficult to break the pattern of self referral, especially with the incentive of quick financial gain. It may appear as difficult for the clinician imager to refer patients to competing clinicians as it is to refer to radiologists. In contrast, the radiologist who works on referral has nothing to lose or gain by making recommendations for further treatment. From my viewpoint, transfer of care that comes with referral preserves objectivity in imaging. Quality of service must be considered as well. Studies by Pennsylvania’s Blue Shield on image quality of radiographic film (6) and by US Healthcare specifically on ultrasound services performed by nonradiologists (7) found
Fury Over Sound that images performed at clinicians’ offices often did not meet accepted guidelines for quality. Several Blue Shield studies have shown that self referral results in a significant decline in the quality of imaging (8 –10). It is easy to understand that images generated by radiologists are subjected to more scrutiny and therefore must be superior. As a rule, radiologists document images meticulously and they generate detailed written reports. Nonradiologists may be more complacent with respect to quality by reading their own images. Accuracy of interpretation represents another quality factor to be considered. Comparisons of ultrasound interpretation by radiologists and rheumatologists have not yet been studied. Many prior studies of radiograph and CT interpretation have shown, however, less accurate interpretation by nonradiologists than by radiologists (7–12).
Reimbursement There are those who consider the ultrasound transducer as the “stethoscope” for an advanced clinical examination of the musculoskeletal system. If indeed ultrasound becomes so universally available as the use of the stethoscope, insurers and patients may have to be ready for great variability in the expertise of those using MSUS. Another factor to consider is that the use of the stethoscope spread at a time when medicine had no subspecialization and no third-party payers guaranteeing compensation. Back then, advancement of medicine was the sole incentive for universal utilization of auscultation during patient visits. If then MSUS becomes the standard of care in a musculoskeletal practice, we will have to brace ourselves for steeply declining reimbursements for such examinations. Recent studies on the utilization of ultrasound in musculoskeletal practices have already shown a dramatic increase in the number of MSUS studies done by nonradiologists. As a matter of fact, the most significant percentage increases in Medicare reimbursements for musculoskeletal ultrasound utilization have been in podiatry (13). How long will it take for MSUS fees to be included in compensation for a patient’s clinical examination? In that scheme of things, how should an ultrasound be reimbursed if done on better equipment, by a better-trained examiner, and in a setting of referral rather than routine visit? Accreditation of individual centers by the American Institute of Ultrasound in Medicine or by the American College of Radiology could help endorse proper utilization of ultrasound. In obstetric and in abdominal ultrasound, this type of accreditation already discriminates the multitude of practices. Certification, which applies rigorous standards of care, will indeed be necessary if we want growth in ultrasound to be development and progress and not mere expansion. At this time, the American College of Radiology’s Committee on Ultrasound Accreditation is considering separate MSUS accreditation (Benson J: personal communication).
Research Can the current practice of the rheumatologist be improved by adding ultrasound equipment to the clinic? Rheumatologists aspirate and inject joints guided by bony
879 landmarks. Ultrasound may be used to assist in such procedures. Would aspiration of a joint yield more fluid and would the injection be less painful or more precise if guided by ultrasound? Research will be needed to assess whether rheumatologists can make improvements over established techniques. Placing needles under ultrasound guidance demands great left and right hand coordination and knowledge of the principles of ultrasound. Procedures often require more than one examiner. In the practice of such joint aspiration and biopsy, there is great potential for radiologists and rheumatologists to cooperate. Ultrasound has also been advocated for assessment of synovial disease in studies published as far back as 1988 (14). Assessing synovial thickness may be possible but how does that change patient management? Most of the research in MSUS has focused on diagnoses that can be managed surgically. In fact, clinical research dates back to the mid 1980s when radiologists were searching for more efficient and less invasive methods to evaluate tendon disease prior to orthopedic intervention (15,16). Arthritides, on the contrary, still present us with many challenges in terms of imaging. The following 10 years of musculoskeletal ultrasound research may well focus on potential applications of ultrasound in rheumatology.
Conclusions The fate of the electrocardiogram, which at first was an investigational tool in the hand of few experienced cardiologists and which now is used by almost every health care worker, could well foretell the future of musculoskeletal ultrasound. Many may soon practice this new application, which has been in the hands of an experienced few for almost 2 decades. Nobody will argue that many users of EKG can read the effects of large myocardial infarcts on electric tracings; at the same time, few will disagree that reimbursements should be linked to knowledge, and that cardiologists read finer detail that remains invisible to a practitioner with less experience. Similarly, short courses in musculoskeletal imaging are unlikely to produce imagers who will be able to discern fine detail necessary to excel in diagnosis. Expertise will be needed, and we agree with Brown et al (1) for their insistence on educational standards. Critical analysis shows that the type of service provided with musculoskeletal ultrasound, reimbursement issues, and research will need considerable attention as well. The last thing we want to see happen is that operator dependency of the ultrasound technique will lead to operator complacency unchecked in the hands of self referral.
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